Provider Demographics
NPI:1477046787
Name:IM, JIHWON
Entity Type:Individual
Prefix:
First Name:JIHWON
Middle Name:
Last Name:IM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S BERENDO ST APT 109
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-2165
Mailing Address - Country:US
Mailing Address - Phone:213-804-0928
Mailing Address - Fax:
Practice Address - Street 1:4870 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-2634
Practice Address - Country:US
Practice Address - Phone:213-804-0928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-11
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15600171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty